Key words: emergency department; utilization; repeat visit; psychosocial disorders; care plan. Acad. ..... vices, psychiatric support, and âroutineâ office visits.
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ACADEMIC EMERGENCY MEDICINE
JUN 1997 VOL 4/NO 6
Frequent Users of the Emergency Department: Can We Intervene? Linda L. Spillane, MD, Eileen W Lumb, MS, RN, CS, Daniel J. Cobaugh, PharmD, Susan Riley Wilcox, MSW John S. Clark, MPP, Sandra M. Schneider; M D
I
ABSTRACT
..................................................................................................................................
Objective: To determine whether the use of individualized patient care plans and multidisciplinary case management would decrease ED utilization by frequent ED users. Methods: The authors performed a prospective, randomized clinical trial of the impact of a care plan on ED use by adults with frequent ED visits. Patients with >10 ED visits to a university hospital in 1993 were identified. Patients were matched for age, sex, and number of visits and then randomized into 2 groups. The control group received standard emergency care. The treatment group was managed by a multidisciplinary team and treated in the ED according to individualized care plans. ED use was tracked at the university hospital and at the other 5 community hospitals in the city. Results: Of the 70 enrolled patients, 25 of 37 control patients and 27 of 33 treatment patients made visits to the university hospital during the I-year study period. Only those patients with follow-up visits were included in the data analysis. Patients remaining in the control group made 247 total visits (range 1-65) to the university hospital and 179 total visits (range 0-38) to the community hospitals during the study period. Patients in the treatment group made 320 total visits (range 1-72) to the university hospital and 254 total visits (range 0135) to the community hospitals during the study period. There was no significant difference in the median number of visits made to either the university hospital or the community hospitals by the patients in the control group and those in the treatment group. Conclusions: The use of individualized care plans and case management did not significantly decrease ED utilization by frequent ED users. However, the impact of individualized care plans and case management on other quality-of-care measures (e.g., patient satisfaction, ED length of stay, hospitalizations, primary care visits, and health care costs) remains to be determined. Key words: emergency department; utilization; repeat visit; psychosocial disorders; care plan. Acad. Emerg. Med. 1997; 4:574-580.
I Frequent ED use for nonurgent problems is thought by
some to contribute substantially to the high cost of medical care.’ Although some authors refute the fact that ED care is expensive’ and we struggle as a profession to define urgent vs nonurgent and necessary vs unnecessary visits,’ most providers would agree that use of the ED as
the sole source of medical care is neither efficient nor the ideal way to provide comprehensive medical care. Frequent ED use has been associated with a lack of a primary care provider/lack of timely access to primary care, social isolation, violence, and alcohol- and drug-related p r o b l e m ~ . ~ -Although ’~ several studies have de....................................................
From the University of Rochester, School of Medicine, Rochester. Ne Department of Emergency Medicine (LLS, EWL. DJC, SRW. JSC,
SMS 1. Received: August 7 , 1996; revision received: October 30, 1996; accepted: November 17, 1996; updated: December 8. 1996.
Prior presentation: SAEM annual nieetiiig. Denver, CO. May 1996. Address for correspondence and reprints: Linda L. Spillane. MD, Department of Emergency Medicine. Universct2, of Rochester; 601 Elmwood Avenue, Box 655, Rochester, NY 14642. Fax: 716-461-9778: e-mail: Ispillan @ed.wnnc.rochester:edu
Frequent ED Users, Spillane et al.
scribed demographic characteristics and psychosocial characteristics of the population who use the ED frequently, we were unable to identify any studies in the literature that looked at interventions to decrease ED utilization in this group of patients. The purpose of this study was to determine whether the use of individualized patient care plans and multidisciplinary case management would decrease ED utilization by frequent ED users.
I METHODS Study Design: This was a prospective, randomized, controlled study of the effect of ED care plan use on ED utilization by adults with a history of frequent ED use. The study was approved by the university institutional review board without the need for informed consent. Setting: The study was conducted at a university teaching hospital and tertiary care center with approximately 60,000 ED patient visitdyear. The ED is staffed by fulltime emergency medicine (EM) faculty, nurse practitioners, EM residents, and rotating residents from surgery and internal medicine. The EM faculty member supervises the care of every patient seen by residents and nurse practitioners. Monroe County has a population of approximately 750,000 and includes the city of Rochester, population 250,000. The county contains 7 hospitals: 6 located in the city and 1 located in the extreme northwest section of the county. The city hospitals include the university teaching hospital as well as 5 community hospitals-1 larger hospital that serves as an area trauma center and 4 smaller facilities. Encounters by patients in the study population were tracked at all 6 hospitals clustered in the city of Rochester. Study Population: The ED computer database was used to identify all patients >18 years of age who made 210 visits to the university hospital ED in 1993. The 70 patients identified were stratified by age, sex, and number of visits and then randomized into 1 of 2 study groups. Stratification and randomization were carried out by a statistician who was not familiar with the patients. Randomization was designed to achieve balanced results for the stratified variables and was performed by drawing repeated random assignments and discarding those not having the desired balance. The treatment group was assigned 33 patients and the control group was assigned 37 patients. Study Protocol: The study was conducted for 1 year, from October 31, 1994, to October 30, 1995. Prior to the actual study period, the investigators reviewed all available inpatient and outpatient medical records for all pa-
575
tients assigned to the treatment group. Individualized care plans were developed, which included a social and medical history, typical ED presentation, and suggestions for care, as well as the phone numbers of involved social workers, physicians, clinic nurses, and family members. The care plans were written by the physician investigator and 1 of 6 emergency nurse practitioners who were familiar with the patients. Each care plan was reviewed and approved by both the physician and the nurse practitioner investigators. Examples of suggestions for care included suggestions to limit x-rays and laboratory tests, protocols for pain management for patients with sickle-cell disease, and places to which the patient could be safely released from the ED. The care plans contained cautions and guidelines for care and were not intended to replace physician judgment. The appendix shows a sample care plan. These care plans were kept in the ED and were available to the ED personnel at all times. The EM faculty and residents, the patient en roller^'^ (a group of paramedics and premedical students trained to identify eligible study patients), and the triage nurses were inserviced about the use and location of the care plans. A list of patients assigned t o the intervention group was placed at triage and in the patient enroller manual, which each enroller carries during his or her shift. Data regarding compliance with the care plans were collected to monitor physician and nurse practitioner use of the care plans as a method of ensuring that the intervention was actually occurring. Once the study period started, patients i n t h e treatment group were identified at triage by a triage nurse (24-hour/ day coverage) or the trained study enrollers (who provide coverage during the 16 busiest hours of the day). The individualized care plans were placed with the chart for provider use. As soon as possible after the initiation of the study, patients in the treatment group making a visit to the university hospital received a social work and/or psychiatric evaluation. The purpose of the evaluation was to identify psychosocial factors possibly contributing to frequent ED use. Patients could refuse t o speak to the social worker or psychiatrist. Upon the initial visit, a primary care provider was appointed. Multidisciplinary case conferences were held soon after the patient made an initial visit and was evaluated by the social worker and/or psychiatrist. Conferences were attended by the EM physician investigator (LLS), emergency nurse practitioner (EWL), primary care provider or clinic nurse, social worker, and psychiatrist or psychiatric nurse. Conferences focused on coordinating each patient’s care both in the ED and within the outpatient clinic setting, and strategies to coordinate care outside the ED. Efforts were made to encourage primary care delivery through the outpatient clinic. Throughout the study, care plans were updated at each
~
576
I
ACADEMIC EMERGENCY MEDICINE
TABLE 1 Characteristics of the Patients Making Visits in Both 1993 and 1994/1995
..............................................................................
Control (n = 25)
Sex-%
men
Age-mean
(range)
48%
39(20-81 years)
Treatment (n = 27) 488 38(18-74 years)
Race/ethnicity Black Hispanic White
44% 4% 52%
63%
Insurance Medicaid Medicare Private
48.0% 44.0% 8.0%
40.7% 51.8% 7.5%
Ambulance use
27.9%
21.3%
% Treated and released
87%
82%
Source of primary care University medical clinic Other clinic Private physician None identified
40% 16% 12% 32%
52%
4%
3390
4%
centage of visits resulting in being treated and released from the ED in 1993 and during the study period. The median number of visits to the university hospital and to the 5 community hospitals was collected for both 1993 and the study period. Information concerning chronic medical conditions and the presence of substance abuse or psychiatric problems was gathered during chart review. The identified source of primary care as well as each patient’s most commonly occurring chief complaints upon presentation to the ED were obtained from the ED registration data base. All available charts were reviewed by the nurse practitioner investigator (EWL) for provider compliance with the use of the care plans and in following suggestions for care. Care was classified as compliant if the suggestions for care were followed or if the reasons for deviation from the protocol were documented.
Data Analysis: Data analysis was done using the MannWhitney U test for medians. A p-value of ~ 0 . 0 5was considered significant.
I
7% 37%
visit. Interventions were made based on identified needs and were patient specific. For example, the primary care of 1 patient was transferred from the medical clinic to a private physician in the community in an attempt to better coordinate the patient’s care. This patient had been seen sporadically by the gastrointestinal, orthopedic, and medical clinics. The care of another patient with a somatoform disorder was transferred from the medical clinic to an internist/psychiatrist who was better able to manage the patient. Prescriptions for a patient with chronic disease and an identified drug abuse problem were written by 1 physician and filled by 1 pharmacist. This patient was successfully enrolled in a drug treatment program. Whenever possible, a follow-up appointment with the primary care provider was made for the patient at the time of the ED visit. Patients in the control group received standard ED care. Consultations with social work or psychiatry, contact with primary care providers, and attempts to enroll patients in alcohol- and drug-treatment programs were initiated at the discretion of the treating physicians, nurse practitioners, and ED nurses on a case-by-case basis.
Measurements: Patients were included in the data analysis if they registered to be seen in the university hospital ED at least once during the l-year study period. These patients were compared for age, sex, race/ethnicity, type of insurance, number of visits, ambulance use, and per-
~~~~
JUN 1997 VOL 4/NO 6
RESULTS
.........................................................................
Of the 70 patients identified for this study, 18 were excluded because they made no visits to the university hospital ED during the study period. Twelve of 37 conrrol group patients were excluded. Three of these patients died between December 31, 1993, and October 31, 1994. The causes of death for these patients were: subdural hematoma; end-stage renal disease; and complications of myelodysplastic syndrome. Five other excluded patients were seen at 1 of the community hospitals but not at the university hospital during the study period and 4 patients never made an ED visit. Six of 33 patients in the treattnent group were similarly excluded. One patient died of congestive heart failure and pneumonia before the start of the study period, 2 made ED visits to the community hospitals but not to the university hospital, and 3 made no ED visits. The patients included in data analysis were similar with respect to age, sex, race, type of insurance, use of emergency medical services, and percentage of visits resulting in being treated and released from the ED (Table 1).
There was a high degree of both substance abuse and psychiatric problems in both the treatment and the control groups. Specifically, 10 of 25 (40%) patients in the control group and 10 of 27 (37%) patients in the intervention group had an identified problem with alcohol and/or other drugs. Similarly, 14 of 25 (56%) patients in the control group and 13 of 27 (48%) patients in the intervention group had an identified psychiatric problem. Chronic medical conditions also were identified (Table 2). The 25 patients remaining in the control group made a total of 247 visits to the university hospital during the
577
Frequent ED Users, Spillme et al.
I . TABLE 2 _.
Patient* c1 c2
c3 c4 c5 C6 c7 C8 c9 CIO c11 c12 C13 C14 CI 5 C16 C17 Cl8 C19 c20 c 21 c22 C23 C24 C25
T1 T2 T3 T4 T5 T6 T7 TS T9 TI0 T11 TI2 TI 3 TI4 TI5 TI 6 TI7 T18 T19 T20 T2 1 T22 T23 T24 T25 T26 T27
Medical Conditions and Chief Complaints of the Patients Presenting .to the ED ............ Chronic Medical Conditions* Tibia fracture, nonhealing Umbilical hernia repair, COPD Alcohol-related seizures
P*
S*
X
X X X
X X Asthma Aplastic anemia Pregnancy Congestive heart failure, CAD, a-fib Sickle-cell anemia
X X
X X X
HIV infection Seizure disorder
X COPD, pneumonia Sickle-cell anemia
X Adult-onset diabetes Pregnancy Posttraumatic leg amputation Seizure disorder
X
X Sickle cell anemia Sicklelthalassemia
X X
X
X X
X
HTN, mild mental retardation
Crohn’s disease Hepatitis A End-stage renal disease, CAD Obstructive sleep apnea Sickle-cell anemia Obstructive sleep apnea
X X
X
X X
X Seizure disorder
X X CAD Colitis, degenerative joint disease Pregnancy Sickle-cell anemia
X X X X
Adult-onset diabetes, pseudoseizure Pancreatitis, HIV infection
X X
X X
Common Chief Complaints* Minor trauma, ETOH Minor illness, staple removal Minor trauma, ETOH, seizure Minor illness, minor trauma Altered mental status Shortness of breath Psych problem Chest pain Vaginal bleeding, dental problem Shortness of breath Sickle cell pain, shortness of breath Dizziness, injury Withdrawal Seizure, minor illness Psych problem, drug reaction Suicide attempt, earache, trauma Injury Psych problem Shortness of breath Sickle-cell pain Psych problem Chest pain Injury, psych problem Psych problem Psych problem, cough
Minor illness, rash Sickle-cell pain Sickle-cell pain Alcohol intoxication Dizziness, fall Injury Injury Abdominal pain, nausea Psych problem Shortness of breath Minor illness, UTI Sickle-cell pain Abdominal pain, gynecologic problem. UTI Anxiety, shortness of breath Psych problem Injury, minor illness Injury Psych problem Chest pain Knee pain, abdominal pain Abdominal pain, injury Sickle-cell pain Psych problem Psych problem, allergic reaction Allergic reaction Abdominal pain Iniury, minor illness
*P = psychiatric history; S = substance abuse history; C = control group; T = treatment group; ETOH = ethanol use (acute intoxication); COPD = chronic obstructive pulmonary disease; CAD = coronary artery disease; a-fib = atrial fibrillation; HIV = human immunodeficiency virus; psych = psychiatric (acute); HTN = hypertension; UTI = urinary tract infection.
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ACADEMIC EMERGENCY MEDICINE
study period, with a range of 1-65 visits/patient. The 27 patients in the treatment group made 320 visits to the university hospital, with a range of 1-72 visitdpatient. Individual ED utilization was highly variable, skewing the data. There was no significant difference in the median number of visits made to the university hospital by the patients in the control group and those in the treatment group in 1993 (13 vs 14; ranges 10-31 vs 10-41) or during the study period (6 vs 7; ranges 1-65 vs 1-72). During the study period, the patients in the control group made a combined total of 179 visits to the community hospitals, while the patients in the treatment group made a combined total of 254 visits to the community hospitals. There was no significant difference in the median number of visits made to the community hospitals in either 1993 (3 vs 1.5; ranges 0-22 vs 0-33) or during the study period (2 vs 2; ranges 0-38 vs 0-135). Two patients in the control group died during the study period. Patient C5 died from a subdural hematoma and patient C11 died of staphylococcal sepsis. One patient in the treatment group, patient T2, died of staphylococcal bacteremia and respiratory failure (Table 2). During the study period, the 8 patients in the control group who identified their source of primary care as the university hospital clinic made 3 1 appointments and kept 13 appointments, for a no-show rate of 58%. The 14 patients in the treatment group who identified the university medical clinic as their source of primary care made 120 visits and kept 81 visits, for a no-show rate of 33%. All available medical records of the patients in the treatment group were reviewed by the nurse practitioner for compliance with care plans. One entire medical chart containing 72 individual ED visit records was missing. The remaining 26 charts were reviewed. Twenty-three of these charts were missing 2 1 individual ED record. Sixtytwo percent (198/320) of the individual ED visits were available for review. Provider compliance occurred in 91% of these ED visits.
I , .DISCUSSION . . . . . . ......................
..........................................
...
Despite an intensive effort and the collaboration of physicians, nurses, nurse practitioners, social workers, and psychiatric providers, we were unable to reduce ED visits by patients who had used our ED frequently. The problem of frequent ED use is complex and multifaceted. Frequent ED use has been associated with perceived ill health as well as deteriorating health.’ Some studies have shown a relationship between social isolation and increased ED use. People who live alone7 or lack friends or social make more visits than do people with a strong social support system. Alcohol-related problems7.’ and psychiatric illness’ are also significant factors in ED utilization. A high frequency of substance abuse and psychiatric illness contributed heavily to ED
JUN 1997
VOL 4 / N O 6
utilization in our study. Frequent ED users, defined in a Swedish study as those making >4 visits in a year, had an excess mortality from violence, alcohol, and probable suicide, as compared with other ED users.” The mortality in our identified group was high; 7 of 70 patients died within 2 years of being identified as a frequent ED user. The number of visits used to define the “frequent” ED visitor varies widely from 2 2 visits per year4 to 12 visits in the preceding year.7 This makes it difficult to compare the populations studied. We defined the frequent visitor as someone making 210 visits in 1 year-a visit frequency much greater than those used by most studies -because we believed it would give us the best possibility of detecting a difference based on our intervention, given the available funding. It may be that we selected a group that was the most recalcitrant to change. A major determinant in ED use, particularly for nonurgent complaints, may be inadequate or inconvenient primary care resources. Lower socioeconomic status appears to be associated with more frequent ED ~se~~~--possibly because of a lack of clinics and primary care providers for this population.’’ A telephone survey to outpatient ambulatory care clinics in urban areas demonstrated a lack of timely care (within 2 working days), a lack of afterhours care, and the presence of a copayment requirement as barriers to Medicaid recipients’ receiving care for nonurgent complaints outside of the ED.’* In another study in which physicians were given clinical vignettes about patients with chronic disease, a lack of access to primary care was associated with a greater likelihood of patient admission.13 Our hypothesis that an attempt to coordinate home services, psychiatric support, and “routine” office visits would decrease ED utilization was not substantiated. We chose the number of ED visits as our outcome marker rather than “appropriateness” of the visit for determining whether the intervention was effective. It was the belief of the investigators that if patients with chronic medical conditions had coordinated medical care and if patients with drug and alcohol problems could be referred systematically to programs aimed at correcting the underlying problem, then the frequency of ED visits would decrease. This concept is variably supported in the literature. Yang et al. found that patients with sickle-cell disease followed in a comprehensive clinic with a multidisciplinary approach to care made significantly fewer ED visits than did patients not enrolled in this ~ 1 i n i c .However, I~ Hand et al. found that access to primary care alone was not associated with fewer ED visits in their group of patients with sicklecell disease.” Redelmeier et al. found that ED visits by the homeless decreased when “compassionate” care was offered by volunteers.” It may be that the nature of the “therapeutic” interaction, whether it occurs in the ED or in a primary care location, is a significant determinant of when and where patients seek medical care.
579
Freouent ED Users. Svillane et al.
I . .LIMITATIONS . . _ . . _ . . . . _ . . . . . . . . . . . . .AND . . . . . . . . . . FUTURE . . . . . . . . . . . . . . . . . . .QUESTIONS ............ - . .... There were several limitations to this study. Although we included every patient meeting the entry criteria, our sample size was small. Additionally, the total number of visits made by patients in both the control group and the treatment group to the university hospital and to the community hospitals decreased during the study period as compared with 1993, limiting the power of the study. Although this may simply reflect the tendency of skewed data to gravitate toward the mean, the cause of overall decreased utilization by this group is unknown. At the time of this study, mandatory managed care for patients on Medicaid was not in effect, and therefore probably did not have a significant impact on ED utilization by patients in either the treatment or the control group. There was no change in the staffing patterns of attending physicians, residents, or nurses during the intervention period. The number of ED visits remained fairly stable between 1993 and 1995, with 58,316 visits in 1993, 57,709 visits in 1994, and 59,095 visits in 1995. Waiting times to be seen were not routinely collected prior to the study period, but there has been a trend downward in ED length of stay (LOS) since 1994, which overlaps with the intervention period. Because we examined ED visits to every hospital in the city, we believe that we captured the majority of ED visits made by all of the patients. We doubt that patients commonly left the city and county to seek care at small outlying hospitals. We were unable to capture outpatient visits made to private offices and outside clinics. As noted above, we chose the number of ED visits as our outcome criterion for several reasons. Some authors have attempted to evaluate ED utilization in terms of appropriateness of visit.’’ We did not attempt to retrospectively determine whether ED visits were “appropriate” when choosing our study population. There is no commonly accepted definition of “appropriate.” Baker et al. recently showed that the patient’s perception of severity of illness and the need to seek immediate care were major determinants of ED use.” Second, not all visits were initiated by the patient. Some were prompted by family members, police, or other social service agencies. Thus, visits that may have been deemed “inappropriate” by retrospective chart review could have been mandated by an outside agency. Finally, the complex social and psychiatric problems of many of the patients in the study population make classification of appropriateness exceedingly subjective. Other outcome parameters, including quality of care, patient and staff satisfaction, and cost, are important outcome measures not directly assessed in this study. It is difficult to measure quality. Subjectively, we believe that the patients in the treatment group received care that was of better quality than that received by the patients in the control group, because the health care providers had a
complete history available to them and received an individualized mutidisciplinary approach to their care. Although we did not specifically measure staff satisfaction with the care plans, the nursing staff in particular expressed support for the project-frequently approaching the investigators to write care plans for patients who were actually in the control group. The nursing staff thought that the treatment group patients benefited from a consistent approach to care. This phenomenon is problematic, however, because it is possible that care plan use for one group of patients may have influenced the care provided to other patients who were identified by the staff to be frequent ED users. It would have been impossible, however, to blind the staff t o which patients were frequent visitors. The belief was also expressed that having care plans for “problem” patients decreased the ED LOS. The impact of individualized care plans and case management on LOS and other quality-of-care measures (e.g.. patient satisfaction, number and length of hospitalizations, primary care clinic visits, and total health care costs) may yet prove favorable.
I CONCLUSIONS In this prospective, randomized clinical trial, the use of individualized care plans and case management did not significantly decrease ED utilization by adults who were frequent ED users. However, the impact of individualized care plans and case management on other quality of care measures (e.g., patient satisfaction, ED LOS, hospitalizations, primary care visits, and health care costs) remains to be determined. The authors thank Christopher Roe for statistical support and Maureen Nelson and Judy Rosenthal for their assistance with data entry. Supported by a University of Rochester Innovations in Patient Care Grant.
IREFERENCES 1. Health Care Advisory Board. Redefining the Emergency Department: Five Strategies for Reducing Unnecessary Visits. Washington, DC: Advisory Board Company, 1993. 2. Williams RM. The cost of visits to emergency departments. N Engl J Med. 1996; 334:642-6. 3. Derlet RW, Wagner MC. Keeping non-urgent patients out of the emergency department: would it make a difference? SAEM Newslett. 1994; 7(6):4. 4. Ullrnan R. Block JA. Stratmann WC. An emergency room’s patients: their characteristics and utilization o f hospital services. Med Care. 1975; 13:1011-20. 5. Shesser R, Kirsch T, Smith J, Hirsch R. An analysis of emergency department use by patients with minor illness. Ann Emerg Med. 1991; 20:743 - 8. 6. Brokaw M, Zaraa AS. A biopsychosocial profile of the geriatric population who frequently visit the emergency department. Ohio Med. 1991; 87~347-50. 7. Purdie FRJ, Honigman B, Rosen P. The chronic emergency department patient. Ann Emerg Med. 1981; 10:198-301.
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ACADEMIC EMERGENCY MEDICINE
8. Andren KG. A study of the relationship between social network, perceived ill health and utilization of emergency care. Scand J SOCMed. 1988; 16:1687-93. 9. Padgett DK, Brodsky B. Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature and recommendations for research and improved service delivery. Soc Sci Med. 1992; 35~1189-97. 10. Hansagi H, Edhag 0, Allebeck P. High consumers of health care in emergency units: how to improve their quality of care. Qua1 Assur Health Care. 1991; 3 5 1 -62. 11. Grumbach K, Keane D, Bindmnn A. Primary care and public emergency department overcrowding. Am J Public Health. 1993; 83: 372-8. 12. Medicaid Access Study Group. Access of Medicaid recipients to outpatient care. N Engl J Med. 1994; 330:1426-30. 13. Bindman AB. Grumbach K. Osmond D. et al. Preventable hospitalizations and access to health care. JAMA. 1995: 274:305-11.
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14. Cobaugh DJ. Spillane LL. Schneider SM. Research subject enroller program: a key to successful emergency medicine research. Acad Emerg Med. 1997; 4:231-3. 15. Yang YM, Shah AK, Watson M, Mankad VN. Comparison of costs to the health sector of comprehensive and episodic health care for sickle cell disease patients. Public Health Rep. 1995; 110:80-6. 16. Hand R, Koshy M, Dom L. Parel M. Health insurance status and the use of emergency and other outpatient services by adults with sickle cell disease. Ann Emerg Med. 1995; 25:224-9. 17. Redelmeier DA, Molin JP, Tibshimni RJ. A randomised trial of compassionate care for the homeless in an emergency department. Lancet. 1995; 345:1131-4. 18. Afilalo M, Guttman A, Colacone A, et al. Emergency department use and misuse. J Emerg Med. 1995; 13:259-64. 19. Baker DW, Stevens CD, Brook RH. Determinants of emergency department use by ambulatory patients at an urban public hospital. Ann Emerg Med. 1995; 25:311-6.
APPENDIX
ED Case Managernens Plan sleep apnea with documented O2 desaturation into the 80s. with a baseline room-air blood gas of pH 7.33, P C O ~of 55 torr, P o z of 59 torr, and 85% saturation. She is currently receiving noc-
Patient Name: Treatment- 14 DOB: 1/23/45 Unit Number: 2222222
Provider Q p e
Primary Care Physician
1 Primary Nurse Gynecology Psychiatry
Name
OPD #3: Dr. DoGood
I
Phone No.
f
Beeper No.
I
222-2222 16-3333
1 OPD #3: B. Good, RN 1 222-3333 1 I Gynecology clinic I 222-4444 I Primary Therapist: Dr. Joy Case Manager: Mr. Bill
222-7777 222-8888
Social History: Significant other moved away in April 1994. The patient’s grandmother, uncle and cousin have all died in the last few months. She lives with her mother, who is very supportive. Background: Ms. X is a pleasant woman who presents to the E D extremely anxious, often with a concern that she is pregnant, or that she can’t breathe. She does not have asthma. Her lungs are usually clear on examination. Ms. X does have obstructive
turnal continuous positive airway pressure (CPAP). The patient can be violent if the provider is aggressive or confrontational.
Suggestions For Care: 1. Do not order laboratory tests until the patient is seen by a physician or nurse practitioner. 2. Do not order a urine pregnancy test if the patient has had one in the last month unless she has abdominal pain or vaginal bleeding or it is otherwise medically indicated. 3. If the patient is short of breath, check an O2 saturation. 4. Offer reassurance.
5. Encourage the patient
to keep her routine gynecology and medical clinic appointments. Make a gynecology appointment for her if she has not been seen in the clinic within the previous 6 months. 6. Encourage the patient to take her prescribed medications. She is often noncompliant with medications. 7 . Prolixin, 5 mg PO, is usually effective for severe agitation.
Disposition/FunctionaI Outcome: 1 . Patient less anxious, not hypoxic. 2. Follow-up appointments made with gynecology or medicine clinic if indicated.
